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Post by Cathy & Sadie on Jul 15, 2023 0:01:10 GMT -7
[Original subject line:IVDD relapse after surgery. Should we get an MRI? ] Hello! I am happy to find this group. We are located in France and it is difficult to get our questions answered here. Our 5 year old, 12 lb, female Coton de Tulear, Sadie ruptured a disk very suddenly on a Sunday night at the beginning of March. She had emergency surgery and was prescribed by the surgeon one month crate rest and the following medications: AINS 10 days. Gabapentine 1 month. Tralieve 10 days, plus at home massages for 20 minutes three times a day. Our regular vet also added laser therapy three times a week and once she was able to walk once weekly hydrotherapy. Her diagnosis: CT scan: Left lateralized extradural spinal cord compression secondary to extrusion of the T12-T13 disc and in a lesser measurement T11-T12 (without particular lateralization). Numerous foci of disc mineralization in situ in the cervical and thoracolumbar region Surgical intervention: T12-T13 hemilaminectomy Parasagital approach left of the intervertebral space T12-T13. Hemilaminectomy and decompression of the spinal cord by removal of a herniated disc of the type Sadie gradually improved and was able to walk and live a normal life, but had nerve damage in one back leg so had been limited in her motion ( unable to jump or stand on two legs or take stairs which we were actually not altogether bad because otherwise it would have been difficult to control her from doing these things). Since then she had one period of shaking and pain [±June 15] (about a month ago) for which our vet gave her an shot for inflammation which was supposed to last 72 hours and we kept her crated for 3 days and she made a full recovery. About a week ago [Jul 8, 2023], however, she had a more serious relapse and [MED LIST/HISTORY- Moderator's Note. Please do not edit
12 lb 5 y.o.
June 15disc episode , crate rest 4 weeks
Jul 8 disc relapse, right rear leg wobbly
no anti-inflammatory Rx'd
gabapentin 100mg 2x/day
traMADol 15mg 3x/day
Morpal (OMEPRAZOLE) ?mg ?x/day ] she is now on Gabapentine 100 mg twice a day and Tramadol 15 mg every 8 hours. She is on crate rest and we only take her out carefully for her needs. The back paw that was weak is significantly weaker now and she hobbles. The vet does not have expertise in IVDD and the surgeon does not recommend that we do anything at this point. There are not specific veterinary neurologists in our area. We are wondering if we should get an MRI as she never had one before? We were never told about giving her anything to protect her stomach while on the medications; I have just discovered this on your blog. Thanks for any feedback! 
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PaulaM
Moderator. 
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 15, 2023 9:15:41 GMT -7
Cathy we are glad you have joined us on the Forum. Know that is is within your power to make an important impact on Sadie's ability to heal her disc. Good news is her symptoms are mild and she's a good candidate for conservative treatment just as the surgeon recommends! How you can help Sadie
🚩Confirm for us you are carrying out the SINGLE most important of care during a disc episode---STRICT rest for 8 weeks to allow the disc to heal. It appears with 4 weeks of rest the early healing disc did relapse Jul 8 causing neuro diminishent of (right or left?) back leg. Proper Crate rest: details with lots of tips to make the next 8 weeks go smoother: ==> dodgerslist.com/2020/05/14/strict-rest-recovery-process/🚩 Verify for us Sadie shows no sign of pain from one dose of meds to the next. Have no patience with pain as it does hinder healing. It is ONLY the resolution of spinal cord inflammation/swelling that provides the relief from pain. It can take an anti-inflammatory (steroid or a non-steriodal NSAID) a range of 7 to 30 days before all swelling is gone. Why is no anti-inflammatory been Rx'd? Call and get a prescription for one.
This page is excellent reading to give you background why an anti-inflammatory and how it works during a disc episode. Knowledge allows you to ask good questions, and better understand the vet. Know ahead of time what your job is when the anti-inflammatory stops or tapers, how to arrange for a Plan B with your vet:
==> dodgerslist.com/2020/04/18/steroids-vs-nsaids/
Why Pepcid AC (famotidine) is used for the duration of any anti-inflammatory drug ==> dodgerslist.com/2020/05/06/stomach-protection/ In the meantime while an anti-inflammatory is working, the best pain medication control is using more than one approach to address pain from multiple fronts (traMADol-general analgesic, methocarbamol- muscle spasm pain, gabapentin-nerve pain). All three pain meds are typically prescribed three times a day for round the clock comfort from pain.
Adjusting meds by phone avoids a risky-to-the disc car transport if you would be observing pain surface. Describe any pain that you're observing.
SIGNS OF PAIN:
⚙︎ shivering-trembling ⚙︎ yelping when picked up or moved ⚙︎ tight tense tummy ⚙︎ arched back, ears pinned bac ⚙︎ restless, can't find a comfortable position ⚙︎ slow or reluctant to move in suite such as shift positions ⚙︎ not their normal perky interested in life selves
🚩 Document medication use. A medication chart is useful to see patterns, have dates and specific facts handy as you discuss things with the vet. D/l a sample and a blank form to use with your dog's meds dodgerslist.com/wp-content/uploads/2020/02/med-chart-printable.pdf🚩 Monitor neuro functions. Keep your vet updated. A quick overview of conservative treatment vs. a surgery PLUS a list of the predictable step by step deterioration of functions to be aware of: ==> dodgerslist.com/2020/02/10/surgery-vs-conservative/🚩 Educate yourself on IVDD to calm your mind, be able to bring things up for discussion and to ask pertinent questions. Be able to advocate for Sadie, recognize well intentioned but harmful advise and politely give it a "no thank you." Gain a realistic idea of how long it takes to heal. This is one of the most frequent questions asked. Here is the answer along with two tools to help you during your dog's recovery time: ==> dodgerslist.com/most-asked-disc-disease-ivdd-questions Shortcut thru IVDD to understand the big picture and living many happy years ahead with Sadie==> dodgerslist.com/2020/06/26/time-and-ivdd/We look forward to learning more about Sadie with your answers: --- Which back leg is wobbly? --- Is pain fully controlled round the clock? --- Why has no anti-inflammatory been prescribed to work on the root cause of pain? Pain meds just block pain. |
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Post by Cathy & Sadie on Jul 15, 2023 21:20:08 GMT -7
[lengthy quoted questions from above post removed. Moderator's prefer to have just the owners words in their posts. Thanks.]
Hello and thank you very much for your response. I am answering your questions below.
We have no problem confining Sadie for 8 weeks. This is the first we have heard of this protocol as the surgeon instructed one month and our vet said after the episode a few days. We desperately need to find a vet here in France that has more expertise and can treat her and prescribe the correct medications. One major question is whether or not she should have an MRI as she never had this type of imagery prior to surgery.
Sadie's neurological damage is to her right back paw. In retrospect this paw has been weak since she was a puppy. We did not realize it at the time as she was always lifting it to pee and we thought that she was trying to imitate male dog behavior. This was the only sign of perhaps a prior problem with the right back paw.
[pain] It is hard to know. She has been lethargic and resting quite a bit. We will keep a close eye on her today.
I'm not sure what to ask for. Our vet told us that Gabapentine 100 mg was an anti inflammatory.
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Marjorie
Moderator~ 
Member since 2011. Surgery & Conservative
Posts: 5,724 
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Post by Marjorie on Jul 16, 2023 5:32:46 GMT -7
The only reason an MRI would be done is immediately prior to surgery so the surgeon knows exactly where to operate. If you're going to do conservative care, then there would be no need for an MRI. Conservative care treats all of the discs so there's no need to know exactly which disc is being affected. At this point, Sadie is a good candidate for conservative care if you ensure that the crate rest is very strict - carry in and out to potty with only a very few steps at potty time. Is Sadie able to put any weight on her right hind paw or does she hold it up flamingo style? If the leg is weak, that's neuro damage but if she's holding it up, not wanting to put pressure on it, that's a sign of pain. Lethargy can be a sign of pain but meds can also cause drowsiness. You'll need to look for two signs of pain. If Sadie is lethargic and also is holding up her paw not wanting to put weight on it, then that would be two signs of pain. Paula detailed the signs of pain to observe above. Gabapentin has a short half life and works best when given 3x/day (every 8 hours). Your vet can also add Methocarbamol which works on the pain of muscle spasms which often accompany a disc episode. Gabapentin is a pain med, specifically used for nerve pain, and is not an anti-inflammatory. Prednisone is a steroidal anti-inflammatory and is the anti-inflammatory most vets use during a disc episode. If the vet will not prescribe Prednisone for some reason, ask for a NSAID such as Meloxicam or Carprofen. As Paula mentioned above, once an anti-inflammatory has been prescribed, a stomach protector such as Pepcid AC also needs to be given so do check with the vet about that, also. Possibly this site will help you find a more knowledgeable vet:ebvs.eu/specialists/find-a-specialist?countryId=0&specialistTitleId=23&search=Healing prayers for Sadie.
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Post by Cathy & Sadie on Jul 16, 2023 7:45:29 GMT -7
Hello.
I can't thank you enough for your help. We have a much better understanding now of what to do.
Sadie does not appear to be in pain - she is not holding her paw up and is not lethargic today.We will keep her confined and add the medications you have noted.
One final question. Should we discontinue her laser treatments? They were really helping after surgery and the vet (who clearly does not know very much about IVDD) has advised we continue. She is just a few minutes away from us.
Thanks again,
Cathy
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Post by Ann Brittain on Jul 16, 2023 8:26:29 GMT -7
If you feel that the laser treatments are helping Sadie, you should continue with them.
Our Buster had laser treatments, and we felt that they helped him recover after surgery. However, we discontinued after the second round of weekly treatments which was a total of about 10 weeks.
I'm glad to hear Sadie is on the road to recovery. We're here to answer your questions and happy to do what we can to help make the process easier for you and Sadie.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 16, 2023 10:32:09 GMT -7
Cathy, after a surgery, the offending disc material has been removed. That makes it WHOLE lot safer to be exposed to a bit more physical activity such as a transport into a clinic for laser therapy. With conservative treatment the offending disc material and the damage to the exterior of the disc exist. This mean too much movement could cause increased damage to the exterior of the early healing disc. This disc damage can well cause then more damage to the spinal cord...meaning diminishment or loss of neuro function. The SINGLE most important care you can give during conservative treatment is limited movement of the spine
As damage to the spinal cord increases, there can be a predictable stepwise deterioration of functions if excessive back/neck movement for example.
Laser therapy Deciding on procedures, whether a vet visit vs. a phone update, etc...each benefit must each be weighed against the potential risk to an early healing disc during conservative treatment with what the benefit would be
Let's see how things stack up by carefully thinking about this excellent therapy and whether it makes sense for Sadie who is doing conservative treatment. Getting up to speed on IVDD, allows you to think, and when well intentioned but harmful advise is presented....gives you the ability to politely say "no thanks." 1) Laser can kick start nerves to self heal- Sadie has very mild neuro diminishment of right back leg wobbliness seemingly no need of a kick start needed. The right rear leg nerves still function with a slight dimishment.. (see above list in this post to see Sadie's status in the big picture). Is a transport into a vet just minutes away and all the potential for movement of the spine worth the risk of too much movement? With Sadie's very mild neuro diminishment, it is very likely she'll self heal with time to a more normal gait and without exposing her healing disc to risk with a trip into the vet. 2) Laser therapy can be an adjunct to difficult pain in conjunction with gabapentin for nerve pain and traMADol as the general analgesic.
Sadie is not even taking the max aggressive pain med use: gaba 3x/day and traMADol 50mg. You report that her lower use of pain meds is providing good pain relief round the clock. So, then, there is no need of laser to help with pain control. There is no benefit for going in for laser, just the risk/danger of too much movement to the spine.
If for some reason you believe you just want laser therapy "because", then seek out a mobile vet who comes to your home.
When you say you'll add some meds, details help us understand best. Please help us out. Give the date, the name of the med and ?mg, ?x/day .
anti-inflammatory drugs
With mild neuro diminshment, as you may have noticed when reading this very informative page, vets typically use a non-steroid anti-inflammatory (NSAID) to get to the root cause of the pain, swollen and inflamed tissue around the spinal cord.
Vets choose an anti-inflammatory during a disc episode to get painful swelling down in about 7-30 days. Vets who practice safe medicine and owners up to speed on medications make all the difference. Did you get all four questions right?
This is an excellent vet directory to inform yoursel about all of Sadie's meds
==> www.marvistavet.com/pharmacy-center.pml
Stay the course with STRICT limited movement of the spine to allow the disc to heal.
Let us know when and which anti-inflammatory has been Rx'd. Make a phone call first thing Monday morning to advocate for a short cours of anti-inflammatory drug. It's been since Jul 8 and nothing to work on inflammation. Just pain meds to cover up pain.
-- mgs per dose, times per day. How many days? Often a vet will choose a 7-day or even a 14 day course of a anti-inflammatory drug. A 2nd course only if proved pain still exists.
-- For the duration of an anti-inflammatory, Pepcid AC (famotidine)
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Post by Cathy & Sadie on Jul 17, 2023 9:33:33 GMT -7
[Central European Summer Time 7:22:56 PM July 17; New York 1pm EST 7/7/]Thank you so much for your feedback and for all of this useful information! We are h olding off on laser treatments for now and have managed to finally find a vet in our area that has experience with IVDD, as her regular vet has absolutely none and the emergency surgeon not at all helpful. We fortunately got in to see him this afternoon.It was suggested that she get an MRI to verify that there is no compression. Your crate rest protocols were all the same as his and the medications that he gave her as as follows: ▼Neurontin [gabapentin] 50 mg 2 x per day for 6 weeks ✙Morpal (unknown PPI) 10 mg per day for 15 days ✙Meloxidyl 1.5 5 units per day for 15 days (unless there are side effects that he noted) [MED LIST/HISTORY- Moderator's Note. Please do not edit
12 lb 5 y.o.
June 15disc episode , crate rest 4 weeks
Jul 8 disc relapse, right rear leg wobbly, no anti-inflammatory Rx'd
✙Meloxidyl® (meloxicam) 1.5mg/1mL as of 7/17: 7.5mgs 1x/day for 15 days, 8/1 TEST STOP for __ pain/ _Neuo issues
Neurontin® (gabapentin) ▼50mg 2x/day ⚠️for 8 weeks! til Sep 11!
traMADol 15mg 3x/day] STOPPED 7/17
✙Morpal (omeprazole) as of 7/17: 10mgs 1x.day for 15 days. STOPS 8/1 ]
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 17, 2023 10:46:42 GMT -7
Cathy, because you observe a diminishment in the right rear leg, that would be consistent with a degree of compression on the spinal cord. Nerves don't like being pressured. Nerve cells can die in reaction to pressure causing diminishment or loss of functions. Knowing that information of existing compression which is still relatively mild, would not change the treatment of conservative... medicines + STRICT rest. The reason for an MRI would be the vet has high suspicion there may be another disease which an MRI could proove. What is that other disease of suspicion? If meds control pain til the anti-inflammatory Meloxidyl STOP TEST on Aug 1 gives proof all swelling is gone, then very likely Sadie is dealing with a disc episode and not some other disease. Question and verify if the vet is HIGHLY suspicious this is not a disc episode and the reason for wanting an MRI. Trip in for MRI, the MRI itself will be involved in opportunties for too much movement for an early healing disc. With Sadie having been proved she was born with IVDD by the surgery last March, very likely this is a disc episode. Know as many facts as you can obtain to be able to weigh the risks of getting an MRI and involving the early heaing disc with unnecessary movement vs. what the MRI benefit would be. NOTE, it seems your highly qualified in IVDD surgeon did NOT say anything about getting an MRI. Local new vet may not have full confidence in his IVDD knowledge and want all bases covered??? Your asking good questions, being a smart detective, can be the very best advocate on behalf of Sadie. Background info: Are you a native speaker of French getting the nuances of speech/communications with the new vet?
What is your city? Time zone in France?PEPCID AC® (famotidine)(When can you get the stomach acids suppressor Pepcid AC® (famotdine) on board? In US it can be purchased at a grocery store, no Rx needed. I think it is the same in France or is an Rx needed from vet?? I can find no info on Morpal. Can you provide more info on what this drug is? Sounds as if it might have morphine in it? On the TEST STOP of Meloxidyl® Aug 1, will be the time to also stop all pain meds to be able to quickly and accurately assess if painful inflamation still exists or not. Pain meds block you from seeing pain. On the test STOP you do not want to have blind-folding Neurontin® (gabapentin for nerve pain) blocking your view of important pain signs should they exist. If Marpol is a pain med, it is being called to stop Aug 1 as pain meds should be stopped for the test. Discuss your concern of being able to accurately observe and avoid delay in finding out if another course of Meloxidyl® would be needed or not. With any STOP of a NSAID, it is always good to have worked out in advance a "PLAN B" should pain re-surface at night or on the weekend when your vet is not open. Could be an emergency RX script you could fill at local 24 hr pharmacy or some extra pills at home til the vet opens again. An ER visit is very expensive, a "Plan B" is free! Let us know what you and your vet have worked out for a Plan B for Aug 1 stop of NSAID. RULE OF THUMB at the stop of NSAID Pain= another course of PRED + all pain meds, GI protector back on board.
No Pain= no meds at all needed...finish out the 8 weeks of crate rest for the disc to heal. Full article about use of NSAID with a disc episode: ==> dodgerslist.com/2020/04/18/steroids-vs-nsaids/With the change in meds, update us on the current observations on pain.
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Post by Cathy & Sadie on Jul 17, 2023 13:07:33 GMT -7
Hi Paula,
I am pasting the english translation of Morpal below.
This medication belongs to the family of proton pump inhibitors (PPIs). It reduces gastric acid secretion, thus helping to combat stomach acid disorders. The vet told us that this is the drug that will protect her stomach from the anti-inflammatory.
The vet that we saw today [Jul 17] is a specialised surgeon that only sees patients when referred by a general vet or hospital. The veterinary surgeons there are all graduates of the european college of veterinary surgery
and/or the american college of internal medicine,
Unfortunately, the vet that did the surgery did not have that much experience under his belt. Our vet today told us that he knows him and that he is a nice guy but has not done enough of these procedures. We did not have options at the time and it looked to me that he had a good background as he graduated from one of the best schools in France - we took her to the emergency hospital [March 2023] on a Sunday night that was recommended and is supposed to have a good reputation as well and they said they would have to operate within a day if she was to have a chance to walk again.
The specialist we saw today [July 17] is not 100 percent convinced that the operation was done correctly after looking a the CT scans and seeing where he operated and doing a neurological check up and he wants to rule out having to have the surgery corrected - if what he is slightly worried about is the case he said that the crate rest won't help. I speak French fluently and so does my husband and the vet also speaks fluent English. We are in the Avignon area of Provence.
He is going to phone me tomorrow about where to do the MRI (as his clinic only has CT scans) and I will ask him to repeat everything he noted about the compression before we take any further steps.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 17, 2023 14:36:20 GMT -7
Cathy, no doubt when in an emergency situation, there is not really time to bone up on things. Often one just does not even know the questions to ask. Just gotta take a surgery action based on one surgeon's opinion. Now you have some time to ask your questions, you can make the best decision based on what you know at the time. That is the best any of us can do. Below are a few idea you can see if you want to consider on your list of questions for the surgeon. After March surgery right rear leg continued to have nerve damage. Note it can take many months for this slowest department of the body to self heal. Think in terms of months rather than days/weeks for this slowest part of the body to heal.  ** After the March surgery was Sadie in noticible pain, indicating maybe a piece of escaped disc material was missed being removed. It is unfortunate, but it can happen to the most practiced of neuro surgeons. Even with pain meds on board, did the neuro detect Sadie still had pain issues, meaning something (escaped disc material?) still pressures the spinal cord. What would be the harm to wait on surgery? I guess that means knowing what "the case" is/ the medical name of the problem. What are the pros and cons to continue with conservative treatment to see if all pain would resolve on it's own. And with time the body will be able to self heal right back leg weakness? It surely helps there is no language barrier in speaking with the specialist! We gladly support both surgery and conservative treatment. Please keep us posted. When you have time, could you share the URL link for Marpol, the PPI. Looking to see the Brand name with the generic active ingredient. Thanks! |
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Post by Cathy & Sadie on Jul 18, 2023 4:07:00 GMT -7
Hi Paula, The active ingredient in Morpal® is OMEPRAZOLE. Here is the link that you requested, however it is in French: base-donnees-publique.medicaments.gouv.fr/affichageDoc.php?typedoc=N&specid=69606819It is very clear that the surgeon that we saw yesterday is significantly more experienced and knowledgable than the emergency surgeon that operated on Sadie in March. We began doubting the first surgeon post surgery when we started asking follow up questions and for further advice. Between him and our local vet that knows nothing about IVDD, we were very frustrated and confused. We would only consider an additional surgery after very careful research and more than one opinion. We would do whatever possible to avoid going through the surgery again unless absolutely necessary. I will post more information as it becomes available and thanks once again for your gracious assistance and care. A follow up note after speaking again to the vet today. His hypothesis is not compression but a possible intraspinal lesion following scarring after her surgery. He noted that this is something that can only be detected by MRI and if exists needs to be treated. Thanks, Cathy |
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 18, 2023 8:41:04 GMT -7
So the diagnosis is not a current disc episode that needs 8 weeks of STRICT rest to allow disc healing? The neuro appearance of increase in back rear leg weakness /wobbly on Jul 8 is not related to a current disruption of the disc's wall, but from scar tissue from a March 2023 surgery?
Until you know for sure this is not a current disc episode, it would be prudent to act as if it were to protect a healing disc with STRICT rest.
Omeprazole is a very good stomach protector. Thanks for the info.
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Post by Cathy & Sadie on Jul 18, 2023 8:53:53 GMT -7
We are not sure yet. The vet [specialist] wants to rule out the possibility of an intraspinal lesion and told us to keep with the strict crate rest until we know for certain based on the results of the MRI. We are having the procedure on Friday and Sadie is safe in her crate in the meantime. Thanks again.
Cathy
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Post by Cathy & Sadie on Jul 21, 2023 22:29:04 GMT -7
[Avignon,France Sat Jul 22 8am; NYC USA Sat Jul 22 2am]Hello, Posting a follow up on Sadie. We took her to the Veterinary Hospital for an MRI as suggested by the local specialist and a Neurologist there
examined her. I'm pasting her conclusions. We agreed to go stick with the conservative treatment for awhile - she is not on inflammatory meds as they caused extreme vomiting and she is not in pain but was prescribed 50 mg of ▲Gabapentine 3 x per day for 2 weeks and then 2 x day for 2 weeks. The neurologist said that it is important for her to walk 3 x per day on the lead 5 to 10 minutes per walk but the rest of the time in the crate. [MED LIST/HISTORY- Moderator's Note. Please do not edit
12.35 lb 5 y.o.
June 15disc episode , crate rest 4 weeks
Jul 8 disc relapse, right rear leg wobbly, no anti-inflammatory Rx'd
7/22 Neuro: T3-L3; delayed paw placement rear legs
Very slight discomfort on thoracolumbar palpation, no neck pain
Differential Diagnois: 1st disc herniation, 2nd meningomyelitis
Meloxidyl® (meloxicam) 1.5mg/1mL as of 7/17: 7.5mgs 1x/day for 3 days, stopped 7/22 due to vomiting
gabapentin as of 7//22: 50mg ▲3x/day for 2 weeks, then 2x/day for 2 weeks.
Analysis: General examination: Good general condition, mucous membranes pink and moist, CRT = 2s, abdominal palpation soft and painless, cardiac auscultation normal. cardiorespiratory auscultation, weight: 5.600 kgNervous system examination: - Mental status and behaviour: normal - Posture: normal - Gait: ambulatory, xyphosis, small step on pelvic limbs, proprioceptive ataxia of PM, no paresis or lameness - Postural reactions: proprioceptive delay in pelvic limbs, normal in thoracic limbs - Spinal reflexes: normal withdrawals on all 4 limbs - Sensitivity: nociception present in PM - Pain: no pain on cervical palpation and very slight discomfort on thoracolumbar palpation - Cranial nerves: normal reflexes and responses Neurolocalization: spinal cord T3-L3Conclusion In the current state of investigations, we suspect thoracolumbar myelopathy, with compressive (e.g. herniated disc) or inflammatory (e.g. meningomyelitis) origins (e.g. herniated disc) or inflammatory (e.g. meningomyelitis) are the most likely hypotheses. Complementary examinations (CT scan +/- LCS analysis +/- MRI) are discussed, but not desired at first, given the clinical improvement. A conservative approach is adopted. On the other hand, if there is no improvement or, worse still, a deterioration deterioration, further investigations would become indispensable.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 22, 2023 10:20:59 GMT -7
[Avignon,France Sat Jul 22 6pm; NYC USA Sat Jul 22 Noon]Cathy, thank you for providing the neuro report. These are the concerns for which I would want more information about if my dog before stopping STRICT rest. Too many seemingly conflicting statements in the report. Neuro report you shared says Sadie shows "clinical improvement." --- typically when there is improvement with a treatment, that could mean the treatment and the diagnosis is proved correct. In other words the diagnosis was a disc episode AND Sadie is going in the right direction of healing, therefore the right diagnosis has the matching treatment. STRICT rest is the most important of care during a disc episode. Going on daily walks is not allowed while the disc is taking 8 weeks to form secure scar tissue. If there were a high suspicion of another disease, the neuro would not likely take the approach to wait and see if further deterioration. Instead would want to absoutlely rule out the other disease via a test. On the Forum a number of dogs initially misdiagnosed disc episode ended up having meningitis that needs a different treatment. Only known it was meningitis because neuro had a high suspicion not a disc episode and went ahead with a spinal tap to test the fluid and matching treatment of an anti-inflammatory steroid prednisone (not staying with a non-steroid anti-inflammatory). The neuro has not mentioned in the report a spinal tap for her "2nd most probable disease" meningomyelitis nor use of a steroid which works both for IVDD and for meningomyelitis. PLEASE DO READ MORE from the Merk Veterinary Manual for dog owners: Meningitis and Encephalitis in Dogs. GI TRACT DAMAGE protectors Sorry to just learn Sadie had showed signs of stomach damage of vomiting. The PPIs such as Mopral® (Omeprazole) take about 3-5 days before reaching peak protection efficiency, then it does a very good job. Until then the stomach is not really protected. Pepcid AC® (famodine) protects in 30 mins and why it is preferable for use with a disc episode. Know your stomach protectors ==> dodgerslist.com/2020/05/06/stomach-protection Often use of an anti-inflammatory can continue if a 2nd protector ==> SUCRALFATE is added to Pepcid AC CRATE REST 1) If this is indeed a disc episode, the correct treatment is to make sure the disc can heal. Avoid any distruption that could then worsen pain and neuro status. STRICT REST, then means no daily walks. Only the very fewest of footsteps at potty time to take care of business. 2) If this is a high suspicion to be " ...inflammation of the meninges, the membranous covering of the brain and spinal cord (meningitis), and inflammation of the brain (encephalitis) called meningoencephalitis then a spinal tap to test fluids would give proof ...care may include corticosteroids (i.e. Prednisone), pain relievers, anticonvulsant drugs, fluids, nutritional supplements, and physical therapy." Maureen T. Long , DVM, PhD, DACVIM. Merk Veterinary Manual for dog owners. Meningitis and Encephalitis in Dogs. Oct 2022Please keep us posted on what you and your vet decide about STRICT rest, spinal tap, Pepcid AC, use of a steroid, etc. There is a lot of info to mull over with your vet to come to the best solution for your Sadie.
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Post by Cathy & Sadie on Jul 25, 2023 2:09:12 GMT -7
Hello Paula,
Thanks very much for your detailed reply and sorry for my delay; my husband had his own health emergency these past few days!
We are not taking Sadie on 5-10 minute walks and I am trying to contact the neurologist regarding the spinal tap.
We started with a emergency surgeon with limited experience and no interest in follow up plus our local vet who is fine for vaccines and regular care but has never had experience with IVDD.
Next a specialist with 10 years experience operating on dogs with IVDD but not a neurologist, and finally an actual veterinary neurologist at an acclaimed veterinary hospital an hour and a half away from us (the closest MRI available) so it is quite frustrating not to get correct advice even as we move up the chain of expertise!
I will post when I have more info but in the meantime we are keeping Sadie contained except for when she has to relieve herself.
Best,
Cathy
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Jul 25, 2023 11:00:26 GMT -7
Cathy, you are doing the prudent thing of acting as if this is a disc episode with the STRICT rest until you have a different confirmed diagnosis. And also pursuing if a spinal tap need to be done if there is a HIGH suspicion of meningitis.
Without background ourselves with some knowledges of IVDD it sure is hard to figure out if the vet before us knows their IVDD. Makes it hard to figure out if there is a need to say "no thanks" to well intentioned but harmful advise. Your getting up to speed on IVDD and now maybe some about meningitis, lets you ask the pertinent questions. Kudos to you, keep up the good work.
It is only then when she is fully off gabapentin you actually can get a good read whether all painful swelling/inflammation is gone around the spinal cord when dealing with a disc episode. Looks like not until Aug 6th, gabapentin 50mgs is then reduced to 2x/day for another 2 weeks. Where you might, then, get an indication if steroid prednisone or non-steroid Meloxidyl® is needed. Seems getting into qualified neuro appt ASAP to properly sort things out on which disease she has is very important for the right treatment.
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Post by Cathy & Sadie on Jul 28, 2023 5:24:48 GMT -7
[ Avignon,France Fri Jul 28, 2:30pm; NYC USA Fri Jul 28, 8:30am] Thank you Paula, We are taking her to the veterinary hospital for further evaluation and test [Aug 7] next Friday and keeping her crated until then. She seems to be doing well but we really want to get to the bottom of her full state of health. I appreciate all of the feedback you have given and will keep you posted. All the best, Cathy |
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Post by Cathy & Sadie on Aug 4, 2023 21:30:00 GMT -7
[ Avignon,France Fri Aug 4, 7am; NYC USA Fri Aug 5, 7am] Hello, I'd like to provide an update on Sadie. Yesterday [8/4] she had an appointment at the veterinary hospital in Montpelier for further examinations which were meant to include a CT Scan, followed by a spinal tap and MRI if the CT Scan was not sufficient for evaluation. She only had the CT Scan as the neurologist found everything necessary in those results. I am pasting his conclusions:
Conclusion: as things stand at present, we have identified two herniated discs in the thoracolumbar and caudal lumbar regions.The latter at L4-L5 appears to be at the origin of the recent signs, but the involvement of the one at T11-T12 should not be underestimated. A continuation of strict rest and medical treatment is envisaged by the owners, given the stability of the signs and the absence of pain.of pain. Improvement may occur with continued rest. If signs worsen, it may be necessary to consider to consider surgery to achieve better improvement (after CT and myeloscan control to better define the compression of each hernia). In addition, adapted long-term physical activity should be considered, given the probable predisposition to Sadie's disc herniations.
Treatment:
- ▲Gabapentin 100 mg: Half a capsule morning, noon and evening for 1 month, then continue according to veterinary advice.
- STRICT rest for another 1 month (no jumping, no playing, no stairs, short leash outside only when needed).
[MED LIST/HISTORY- Moderator's Note. Please do not edit
12 lb 5 y.o.
June 15disc episode , crate rest 4 weeks
Jul 8 disc relapse, right rear leg wobbly
Graduation date: Sep 2
8/4 neuro exam "was found to be without pain at her exam on August 4th and was fasting and without a dosage of the medicine for approximately 14 hours"
gabapentin 50mg ▲3x/day. as of Aug 4 for 30 days til Aug 31
traMADol 15mg 3x/day STOPPED 8/4
Morpal (OMEPRAZOLE) ?mg ?x/day STOPPED 8/4 ] The neurologist emphasized that since Sadie has now had 3 herniated disc events, she is seriously predisposed to this happening again in the future. I had considered back in the spring after her first episode and surgery the idea of taking her for PDLA surgery in the US during my next visit home and once she was fully recovered. I communicated with the some of the surgeons in the US that perform this procedure. At the time I decided not to pursue because there did not seem to be studies done on the long term effects and also it appeared that the proponents were these few surgeons but no other specialist that I spoke with or read about seemed to have an opinion. Perhaps now that we know more about Sadie's high likelihood of future issues we will reconsider but I'm not yet convinced that it is the right thing to do. In the meantime we will complete the eight weeks of rest. We were also advised to keep Sadie in a hard plastic transport cage when we need to leave her alone (which is fortunately not frequent) as she becomes overly excited when we return and has a tendency to try to jump when she sees us. |
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Aug 5, 2023 7:26:36 GMT -7
Cathy, now with a confirmed diagnosis of a disc episode, glad you prudently continued on with strict rest. Graduation day will be Sep 2 where the scar tissue on the outside of the disc will be strong enough to begin a slow and gradual return to activity and family life. At that time we'll have many tips and ideas to share with you. Would you use dates/time rather than yesterday. That would help us an save time in looking it up. With conservative treatment the meds are used only til all swelling is gone. The stop of Meloxidy on 8/1 is to find out for sure if all swelling is really gone. Continuing on with gabapentin which blocks pain signs, means you don't know anything about the swelling. Is is gone or just hidden by gabapentin and now hidden for another 30 days!!!? Gabapentin for some dogs with epilepsy should be backed down avoid encouraging a seizure. What was the reason given for extending gabapentin for 30 days reduced to 50mgs 2x/day? Does Sadie have epilepsy? Read more about gabapentin: ==> www.marvistavet.com/gabapentin.pmlMost dogs do NOT like the reduced visibility of those hard plastic crates. If Sadie is one of those, then use a wire crate when you leave the house. To prevent her excitedly jumping up when you return, use this great tip from www.dodgerslist.com/2020/05/14/strict-rest-recovery-process/ TIP: Drape a blanket over the top of the wire crate. Allow the blanket to drape just to Sadie's eye level when she is sitting on her butt. That way when she tries to jump up she will be in the dark and not see anything. Quickly that behavior should be extinguished. Periodically practice it when you are home for the days you will actually leave the house.
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Post by Cathy & Sadie on Aug 5, 2023 20:00:04 GMT -7
Dear Paula,
Thanks very much for this information. I think that Sadie would hate the plastic crate and am very happy to have your tip for the alternative.
I sent the neurologist a follow up email on August 5th for further details about his reasoning behind the increased Gabapentine dosage (after her tests on August 4 he only noted that this was in light of the two herniated discs discovered in the scans) and how we can know whether or not Sadie has inflammation while on the current pain blockers and will report back. She was found to be without pain at her exam on August 4th and was fasting and without a dosage of the medicine for approximately 14 hours at the time of the exam. She also had complete blood testing done during the exam. I am not sure whether either of these points are relevant. Sadie does not have epilepsy.
Thanks again,
Cathy
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Aug 6, 2023 9:40:28 GMT -7
Cathy, thank you for revealing an important piece of information.
"was found to be without pain at her exam on August 4th and was fasting and without a dosage of the medicine for approximately 14 hours."
It seems there had been a mini test of sorts with 14 hrs w/o any pain med on board and no pain detected by neuro.
What would it hurt to stop gabapentin to find out for sure that all pain is actually been resolved? Let us know what your neuro and you conclude.
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Post by Cathy & Sadie on Aug 8, 2023 21:42:30 GMT -7
Hi Paula,
The neurologist noted on August 8th that he increased Sadie's dosage of Gabapentine during our visit on August 4 to 50 mg 3 x per day because he felt after looking at her scans that even though she is not expressing neuro pain he feels there is a high likelihood of some discomfort. He suggests following the course rather than disrupting the schedule. Now he is away for vacation for the rest of August so I think that we will just stick with this for the remainder of her crate rest which ends September 2.
She seems to be doing well with the program although we are wondering if she might benefit from an anti depressant. The reason is that she is a highly emotional dog and she is calm when we are in the room with her but can cry incessantly when she is left alone. She has always been like this and it is hard for her not to be able to follow us everywhere. The crate is in the main part of the house but we are not always present. Thank for your feedback.
Best,Cathy
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Aug 9, 2023 8:00:13 GMT -7
Cathy, just so you know the "usual" about guessing with "feeling" vs knowing for sure if all pain is gone. In order for there to be a graduation, dog should be be off all meds for at least a week to ensure all painful inflammation has been actually resolved. Normally when a vet guesses (feels) swelling might be gone there will be a stop of anti-inflammatory and pain meds. Usually the first course of anti-inflammatory will be 5 or 7 days and then a test stop. Rule of thumb is: pain on stop of NSAID + pain meds =
swelling = more time on NSAID Meloxidyl, pain meds and Pepcid AC needed.
no pain on stop of NSAID + pain meds = no meds at all are needed. Complete the remainder of the 8 weeks of rest. A pet stroller may be your solution for Sadie. You do not need anything with lots of features as it will only be used in the home to keep her by your side. More on features for a pet stroller: dodgerslist.com/2020/05/17/pet-stroller-conservatve-treatment/ |
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Post by Cathy & Sadie on Aug 10, 2023 0:37:52 GMT -7
Hi Paula,
Thank you for another thoughtful response. It would be good to make sure that Sadie has no inflammation via a 'test stop' however during this month of August in France her vets are all on vacation (norm in this country) and when we first took her off of the drug after the prescribed month post surgery (April 7) we were not instructed to taper her off properly and she had a couple of bad days of discomfort. We would rather not put her through that again so wouldn't the 'test stop' require tapering down rather than going cold turkey? At that time we finally were instructed to take her from 300 mg per day to 200 mg per day to 100 mgs per day to then every other day. We thought it might be better to just leave her on the 150mg per day since she is doing so well and then keep her resting for an additional week to watch her carefully for signs of pain after the 8 week period is up. If you have another idea for a test stop now please let me know.
Thanks also for bringing up the idea of the stroller. We do have a good one which we use occasionally. We were concerned about handling her too much - moving her in and out of the crate - and we move around and in and out of the house quite a bit and it is not always practical to bring her along. We also live on multiple levels of a house and are concerned about carrying her up and down the stairs and moving her crate. We are working on helping her to keep calm by positive reinforcement with treats. We will not pursue antidepressants if we can avoid it.
Thanks again,
Cathy
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Aug 10, 2023 8:26:32 GMT -7
Cathy, with the stop of the anti-inflammatory, there two ways to handle the pain meds. It is at the at discretion of the vet if pain meds can be stopped cold turkey or better backed down for their patient's needs. I can imagine with multi-stories, not so easy to keep Sadie by your side. Some members have a recovery suite on each floor. As long as you feel you can safely carry her with little movement of the spine, supporting both ends with back horizontal to the ground, it might be possible to use a stroller on the level you spend the most time on during the day. The stroller could go out on the deck beside your chair for some fresh air. At night, a suite on the bedroom level for her to spend the night with you. You do have a challenge. You know your home and are the one to come up with the best plan.
I like your positive reinforcement approach with treats to help her understand the behavior you want from her. An interesting note is that dogs do not go by the size of the treat. So even the very tiniest bit of treat is just as good as a big higher calorie hunk. |
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Post by Cathy & Sadie on Aug 30, 2023 11:33:55 GMT -7
[Paris, France Wed Aug 30, 8:30 pm;
NYC USA Wed Aug 30, 2:30 pm]
Hi Paula,
In a few days Sadie will have completed her 8 weeks of crate rest. She has been off of the gabapentin for about 5 days so far and is not taking any other medication. So far she is not exhibiting any signs of pain.
You had mentioned in an earlier reply that you have some tips for how to reintegrate her slowly into more activity once the 8 week period has been completed. Thank you in advance for any advice.
Best Wishes,
Cathy
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Post by Romy & Frankie on Aug 30, 2023 13:24:56 GMT -7
Now that Saturday is approaching and Sadie will come off crate rest, she will need to start building up her muscles and stamina. It would be best to GRADUALLY reintroduce her back to activity. We have a sample schedule for doing this at the link below: dodgerslist.com/2020/06/15/back-friendly
Sadie will be able to get back to her regular activities, but there are some that should be permanently avoided:
No more stairs or steps. Use ramps indoors.
No more jumping up or down, those activities increase impact on the spine.
No tug-o-war, pulling games.
No shaking toys.
No zig zag running.
No rambunctious playing with other dogs.
Teach Sadie to not pull on the leash
No sitting up or standing on back legs.
Teach your dog to sit down rather than jump
AND keep all four feet on the ground
There are some modifications you can make to your home to help keep her safe. We have tips on how to do this at the link below: dodgerslist.com/2020/07/09/home-protect-ivdd-backs
Information about therapy for at home or in a rehab center is here: dodgerslist.com/2020/06/26/rehabilitation-therapy |
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,567
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Post by PaulaM on Aug 30, 2023 15:23:04 GMT -7
Cathy, Romy has pointed you to some very useful pages in the above post to help you slowly introduce Sadie back to family life and exercise over the course of a couple a months. Sounds like things are going quite well being off meds & no pain, meaning she will be on schedule for Sat Sep 2 graduation to begin a slow and supervised introduction back to family life. Slow and gradual, because should there be pain, you want to be able to distinguish between having overdone exercise causing muscle discomfort/soreness VS. a new disc episode needing re-crating and vet help Could you bring us up-to-date on the her rear legs. Can she now walk with a normal gait?
Or do the rear paws knuckle under, unable to right them or slow to right them?
Or does she wobbly walk?
Laser Disc AblationHere is some info about the Laser Disc Ablation you had mentioned should you be interested in pursuing it. Dodgerslist has asked a few of the neuros we work with, they really don't seem to have an opinion. As with any surgery there is a risk so best to talk everything over with a vet who does a lot of these procedures to discuss if they believe this is right for your dog. Confirm when choosing, it is a clinic/surgeon with a lengthy history/experience of doing this procedure. There are a limited number of clinics that do LDA in the USA: Garden State www.gsvs.org/neurology-neurosurgery/ Oklahoma State University: news.okstate.edu/articles/veterinary-medicine/2016/disk-surgery-dogs-does-it-work.html Dallas Surgical Center dvsc.com/2020/01/laser-disc-ablation-preventing-intervertebral-disc-disease/ VRC Hospital, Malvern, PAwww.vrcmalvern.com/wp-content/uploads/2020/08/PLDA_neuro_trifold_8-6_AB_RUN.pdfEvery single disc in the spine has the potential to be effected by the ongoing disease process of IVDD. For the LDA procedure only 7 discs are selected to zap (those which seem to herniate most are often located mid back). LEARN MORE Percutaneous laser disc ablation: a proactive approach to minimizing IVDD in dogs October 27, 2022 19:47min podcast: www.dvm360.com/view/percutaneous-laser-disc-ablation-a-proactive-approach-to-minimizing-ivdd-in-dogs------- When LDA was rather new, Dodgerslist contacted Dr. Dugat at Oklahoma State University to learn more about LDA. Dr. Dugat wrote: "I just published a new study "Recurrence of disk herniation following percutaneous laser disk ablation in dogs..." that looked at dogs who had the LDA for a minimum of 3 years after their LDA procedure (this is the time frame that has been documented in the literature to say that we are confident that a recurrence will be less likely to happen). My study just came out in the Dec. 15th 2016 issue of the Journal of the American Veterinary Medical Association. Basically, what this study did was look at the recurrence in a population of dogs that had LDA and were followed up for 3 years. We cannot take these numbers and directly relate them to a group of dogs that did not have the LDA, but we can use this information to show how good of a job the procedure does. We looked at 303 cases. 19.8% of the dogs (n = 60/303) had an episode of SUSPECTED or CONFIRMED disk herniation after having the PLDA, but only 3.6% had a CONFIRMED disk herniation (via CT, MRI, surgery). 19 of the 60 dogs had a suspected episode of pain that resolved on its own in less than 3 days (this is probably not a true recurrence, but we had to include them based on the clinical signs that owners were reporting). 94.4% of owners reported that their dog was the same or better immediately after the PLDA (we want them to come in and leave our hospital the same - normal). Owners rated their satisfaction with the procedure as >/= 9 (1 = completely dissatisfied) and 10 = completely satisfied). The biggest complication seen was during the procedure and was 10%. The most common complication in this percentage was the inability to do the procedure on a disk space because we could not get the needle inserted. The most likely cause for this is probable scar tissue that has developed or collapse of the disk space from a previous rupture. I hope this information helps! Danielle R. Dugat, DVM, MS A follow up is Dugat': 19 July 2021 Evaluation of the intervertebral disk, vertebral body, and spinal cord fsor changes secondary to percutaneous laser disk ablation. onlinelibrary.wiley.com/doi/abs/10.1111/vsu.13684 |
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